Shortages of agents used to treat antimuscarinic delirium.

INTRODUCTION: Antimuscarinic delirium (AD), a potentially life-threatening condition frequently encountered by emergency physicians, results from poisoning with antimuscarinic agents. Treatment with physostigmine and benzodiazepines is the mainstay of pharmacotherapy, and use of dexmedetomidine and non-physostigmine centrally-acting acetylcholinesterase inhibitors (cAChEi) such as rivastigmine has also been described. Unfortunately, these medications are subject to drug shortages which negatively impact the ability to provide appropriate pharmacologic treatment of patients with AD. METHODS: Drug shortage data were retrieved from the University of Utah Drug Information Service (UUDIS) database from January 2001 through December 2021. Shortages of first-line agents used to treat AD (physostigmine and parenteral benzodiazepines) and second-line agents (dexmedetomidine and non-physostigmine cAChEi) were examined. Drug class, formulation, route of administration, reason for shortage, shortage duration, generic status, and whether the drug was a single-source product (made by only one manufacturer) were extracted. Shortage overlap and median shortage durations were calculated. RESULTS: Twenty-six shortages impacting drugs used to treat AD were reported to UUDIS from January 1, 2001 to December 31, 2021. Median shortage duration for all medication classes was 6.0 months. Four shortages were unresolved at the end of the study period. The single medication most often on shortage was dexmedetomidine, however benzodiazepines were the most common medication class on shortage. Twenty-five shortages involved parenteral formulations, and one shortage involved the transdermal patch formulation of rivastigmine. The majority (88.5%) of shortages involved generic medications, and 50% of products on shortage were single-source. The most common reported reason for shortage was a manufacturing issue (27%). Shortages were often prolonged and, in 92% of cases, overlapped temporally with other shortages. Shortage frequency and duration increased during the second half of the study period. CONCLUSION: Shortages of agents used in the treatment of AD were common during the study period and affected all agent classes. Shortages were often prolonged and multiple shortages were ongoing at study period end. Multiple concurrent shortages involving different agents occurred, which could hamper substitution as a means of mitigating shortage. Healthcare stakeholders must develop innovative patient- and institution-specific solutions in times of shortage and work to build resilience into the medical product supply chain to minimize future shortages of drugs used for treatment of AD.

Adult lead exposure from ammunition reloading and indoor residential shooting.

The use and maintenance of firearms is a common and often preventable source of adult lead exposure that is often poorly understood by medical professionals. This case describes an elevated blood lead level (BLL) in an adult man due to the exposure sources of ammunition reloading and indoor target shooting in the basement of his home and details the challenges involved in the diagnosis and management of such cases. The elevated BLL was reduced through strict attention to personal hygiene during the reloading process and while shooting, improved ventilation and cleaning of the basement, and avoidance of vacuuming and use of dry cleaning techniques. Medical providers may be unfamiliar with the risks of indoor residential shooting and how to ameliorate them; this knowledge deficit may result in delays in diagnosis as well as an inability to successfully mitigate the risks for exposure. Time-sensitive diagnosis and treatment, comprehensive risk assessments, and reduction of exposure sources are important facets in the care of adult patients who are exposed to lead through recreational activities. Health care professionals should be aware of the potential dangers of ammunition reloading and indoor shooting, be familiar with ways to reduce lead exposure during these activities, and understand the resources that are available for the management of lead-exposed patients.

Time to perforation for button batteries lodged in the esophagus.

INTRODUCTION: New strategies recently proposed to mitigate injury caused by lithium coin cell batteries lodged in the esophagus include prehospital administration of honey to coat the battery and prevent local hydroxide generation and in-hospital administration of sucralfate suspension (or honey). This study was undertaken to define the safe interval for administering coating agents by identifying the timing of onset of esophageal perforations. METHODS: A retrospective study of 290 fatal or severe battery ingestions with esophageal lodgment was undertaken to identify cases with esophageal perforations. RESULTS: Esophageal perforations were identified in 189 cases (53 fatal, 136 severe; 95.2% in children ≤4 years). Implicated batteries were predominantly lithium (91.0%) and 92.0% were ≥20 mm diameter. Only 2% of perforations occurred in <24 h following ingestion, including 3 severe cases with perforations evident at 11-17 h, 12 h, and 18 h. Another 7.4% of perforations (11 cases) became evident 24 to 47 h post ingestion and 10.1% of perforations (15 cases) became evident 48 to 71 h post ingestion. By 3 days post ingestion, 26.8% of perforations were evident, 36.9% by 4 days, 46.3% by 5 days, and 66.4% by 9 days. CONCLUSION: Esophageal perforation is unlikely in the 12 h after battery ingestion, therefore the administration of honey or sucralfate carries a low risk of extravasation from the esophagus. This first 12 h includes the period of peak electrolysis activity and battery damage, thus the risk of honey or sucralfate is low while the benefit is likely high.

Trends in Shortages of Lead Chelators From 2001 to 2022.

OBJECTIVE: The study aims to describe drug shortages affecting lead chelators in the United States from 2001 through 2022. METHODS: Drug shortage data were retrieved from the University of Utah Drug Information Service from January 1, 2001, through December 31, 2022. Shortages of first- and second-line lead chelators were analyzed. Drug class, formulation, administration route, shortage reason, shortage duration, generic status, single-source status, and presence of temporally overlapping shortages were examined. Total shortage months, percentages of study period on shortage, and median shortage durations were calculated. RESULTS: Thirteen lead chelator shortages were reported during the study period. Median duration was 7.4 months and the longest shortage (24.8 months) involved calcium disodium edetate. Calcium disodium edetate and dimercaprol had the greatest number of shortages, 4 each, and 61.5% of shortages involved parenteral medications. Median shortage duration was 14.2 months for parenteral agents and 2.2 months for non-parenteral agents. All shortages involved generic, single-source products. Supply/demand and manufacturing problems were the most common shortage reasons provided. Overlapping shortages occurred for 3.7% of the study period. Median shortage duration increased from 3 to 11 months in the second half of the study period, and 61.5% of shortages occurred in the second half of the study period. CONCLUSIONS: All chelators experienced multiple shortages, which became increasingly frequent and prolonged over time. Concurrent shortages occurred, potentially hampering substitution between different agents. Health care stakeholders must build supply chain resilience and develop guidelines regarding how to modify chelation therapy based on shortage conditions.

Case study: Cinnamon aspiration in a toddler causing severe ARDS requiring surfactant and extracorporeal membrane oxygenation.

As many as 6% of reported cinnamon poisonings cause significant clinical effects, however, descriptions of pulmonary toxicity have not yet been reported. Here, we present a pediatric patient's hospital course following powdered cinnamon aspiration. The early presentation with hypercapnia and lower airways obstruction evolved to hypoxemic respiratory failure and severe pediatric acute respiratory distress syndrome requiring a 7-day course of veno-venous extracorporeal membrane oxygenation, 16 ventilator-days, and three diagnostic and therapeutic bronchoscopies with two applications of surfactant therapy. The sum of these modalities contributed to this patient's survival and subsequent return to respiratory baseline 6 months post-hospitalization.

Severe scombroid poisoning and life-threatening hypotension.

Scombroid fish poisoning (SFP), the most common fish-related illness worldwide, is a histamine response caused by the heat stable toxin histamine. A healthy 48-year-old woman and co-author of this paper developed palpitations, tachycardia and hypotension 10 min after a tuna steak dinner. She subsequently developed numbness of her face, flushing, conjunctival erythema, abdominal pain, nausea, vomiting, diarrhoea, headache and chest pain. Her ECG revealed tachycardia with ST depression. Her hypotension did not respond to fluid resuscitation, and she required phenylephrine. Based on exposure history, clinical syndrome, exclusion of other diseases and consultation with poison control, a diagnosis of scombroid poisoning was established. The state health department was notified. The patient was weaned off vasopressors, dosed famotidine and discharged 43 hours after fish ingestion with no symptoms and normal ECG. SFP is an often misdiagnosed and underreported illness with the potential to cause life-threatening hypotension.